Healthcare Provider Details

I. General information

NPI: 1447359534
Provider Name (Legal Business Name): ORAL SURGERY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16216 BAXTER RD SUITE 250
CHESTERFIELD MO
63017
US

IV. Provider business mailing address

16216 BAXTER RD SUITE 250
CHESTERFIELD MO
63017
US

V. Phone/Fax

Practice location:
  • Phone: 636-532-3525
  • Fax: 636-532-5782
Mailing address:
  • Phone: 636-532-3525
  • Fax: 636-532-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number013223
License Number StateMO

VIII. Authorized Official

Name: DR. SUSAN ANN GODWIN
Title or Position: ORAL SURGEON
Credential: DMD
Phone: 636-532-3525